Multiple Sclerosis (MS)

Overview

 Multiple Sclerosis (MS) is a

chronic progressive, non
contagious, degenerative
disease of the CNS
characterized by
demyelinization of neurons.
The Human Nervous System
 Areas affected by MS
 Brain
 Spinal cord
 Optic nerves

Pathologic triad
 CNS inflammation

 Demyelination

 Gliosis (scarring)
 History of Multiple Sclerosis
 The earliest description of MS was recorded in
Holland on August 4, 142. But the history of the
disease really begins in the 19th century with the first
clear illustrations and clinical description of the
disease beginning to appear in 1838.

 The first actual case was diagnosed in 1849. It was

Dr. Jean-Martin Charcot who is credited for giving
the first signs and symptoms of Multiple Sclerosis.
Multiple Sclerosis -
Epidemiology
 Worldwide occurrence:1.1 – 2.5 million cases
 Female: male ratio = 2:1
 In Canada an estimated that 55,000-75,000
people have multiple sclerosis
 Affects nearly 500,000 individuals in the US
 Occurs most frequently between ages 25 - 35
Genetic and the Immune
System
XX
2
XX Immune
XX Response
XX XX 10
3
Genes
9 1 XX
XX 6

X
XX XX
13 7
11

XX XX
12 XX XX 5
4
8
 Factors Contributing for MS
Genetic Factors
 Gender: Women are 2 to 3 times more likely to get the

disease.
 Family history of MS: A family history increases the

risk
 Race: MS appears more in Caucasians than in other

groups
Environmental factors
 Latitude: As you increase latitude, mainly above and

below 40° latitude. MS is more common. It is five times

more likely in temperate and cooler climate regions.
World Distribution of MS
 Factors Contributing for MS
Environmental factors
 Socioeconomic status: Least common in rural and

lower class.
 Migration: The age at which you may move may also

be an important factor. “If you move before the age of

15, your risk is likely to that of the people in the country
you move to. If you move after the age of 15, your risk
stays fixed at that of the country
you grew up in”.
 Factors Contributing for MS
Environmental factors
 Infection:

“They believe MS is a delayed reaction to a viral

infection contracted during childhood by a genetically
susceptible person” (O’Connor 13). The viral infections
may include shingles, chicken pox, measles, or certain
herpes. An idea they also have concerns the age at
which you get the infection. The older you are the
higher the risk for MS.

***Remember that in warm countries, children contract viruses at a younger

age.
Not Everyone with a Genetic Risk
Will Develop MS – Why?
 Risk is modified by Environmental
factors
 Sunlight
 Diet (e.g., vitamin D)

 Other lifetime experiences

(infections?)
Multiple Sclerosis - Causes
 The exact cause of multiple sclerosis is not
clear
 MS patients, have a higher number of
immune cells which suggests there might be
an immune response; this is suspected to be
due to a virus or genetic defect
 Other causes are environmental and
hereditary
How Does it work?
 Demyelination of Nerve Fibers
in MS
Positive conduction
abnormalities
generations of spontaneous
ectopic impulses and abnormal
“crosstalk” between demyelinated
axons
 Negative conduction
abnormalities The destruction of the
slowed axonal conduction, myelin sheath leads to
variable conduction blocks occur impaired communication
in the presence of high- but not between nerve cells
-low frequency volleys of
impulse.
Mode of Action
 The immune system attacks axons, causing
destruction of the myelin sheath resulting in a
Conduction Block which leads to permanent loss
of function.
 MS is an Immune-Mediated Disease

BBB=blood-brain barrier; APC=antigen-presenting cell.

Adapted from Miller et al. Continuum: Multiple Sclerosis (Part A). 1999;5:7.
 Pathophysiology
 Autoimmune response results in damage and loss of fibers.
 Nerves can regain myelin, but the process is not fast enough to
avoid the deterioration that occurs
 Astrocytes form scars where myelin formerly existed
 Inflammation, loss of myelin of nerve fibers, and the scarring
that follows result in reduced transmission of nerve signals
within the CNS.
 Type of symptoms and severity vary widely due to the location
of the scar tissue and the extent of demyelination
Click Pathophysiology of MS
Multiple Sclerosis Signs and
Symptoms
 Vision impairment  Memory loss
 Lhermitte‘s sign-  Depression
momentary  Urinary and bowel
paresthesia problems
 Difficulty in walking  + Babinski’s reflex
 Weakness and
exhaustion
Nursing Diagnosis
 Nursing Diagnosis

1. Pain chronic r/t stimulations of free nerve

ending 2 to destructions of myelinated axons.
2. Impaired sensory perception r/t nonsynaptic
transmission of demyelinated axons.
3. Fatigue r/t decrease energy production
4. Paralysis r/t conduction block of demyelinated
axons.
 Cont.. Nursing Diagnosis

5. Low self Esteem r/t change in brain

structure/function.
6. Ineffective coping r/t multiple life changes.
7. Risk for care givers role train r/t severity of the
care receiver, duration of care giving required
8. Deficient knowledge regarding condition,
prognosis, complications, treatment and need
r/t unfamiliarity of information resources.
Multiple Sclerosis - Types
There are 4 major types of MS
 Relapsing-remitting MS (RR-MS)

 Primary-progressive MS (PP-MS)

 Progressive-relapsing MS (PR-MS)

 Secondary-progressive MS (SP-MS)
Multiple Sclerosis - Types
Relapsing-remitting MS (RR-MS)
 More than 80%

 Defined clinical exacerbation of

neurological symptoms
 Followed by complete or incomplete

remission during which the person fully

or partially recovers from the deficits
acquired during relapse
Multiple Sclerosis - Types
Primary-progressive MS (PP-MS)
 10 to 20%

 Gradual progression of the disease

 No overlapping relapses and remissions

Multiple Sclerosis - Types
Progressive-relapsing MS (PR-MS)
 Rare

 Initially presenting as PP-MS, however during

the course of the disease the individuals

develop true neurologic exacerbations
 Steady progression of clinical neurological

damage with superimposed relapses and

remissions.
Multiple Sclerosis - Types
Secondary Progressive MS (SP-MS)
 SP-MS is characterized by a steady progression

of neurological damage with or without

superimposed relapses and minor remissions
 Individuals with SP-MS will have experienced a

period of RR-MS, which may have lasted from

2 to 40 years
 Any super-imposed relapses and remissions

fade over time

 How Is MS Diagnosed?
 At least two episodes of symptoms
 Occur at different point in time
 Result from involvement of different areas
of the central nervous system
 Absence of other treatable causes for
the symptoms
 Results of neurological testing
DIAGNOSTIC WORKUP
Radiologic studies
 It is diagnosed by neurological
examination and brain MRI scans
 Signs of two separate attacks with

demyelination of CNS supports the

diagnosis.
 Magnetic Resonance
Imaging (MRI)
Is a noninvasive diagnostic
scanning technique in which the
client is placed in a magnetic field.
MRI provides a better contrast
between normal and abnormal
tissue than the CT scan. For
visualization of the brain, spine,
limbs, and joints, heart, blood
vessels, abdomen and pelvis.
 
 Brain Atrophy (Shrinkage)
in Untreated MS

Images acquired over the course of 7 years from a single person

with untreated MS Brain atrophy is seen as the enlargement of
the ventricle and sulcal spaces. In untreated MS, by year 2, up to
6% of brain volume can be lost.2
Assessment of the Appearance of
MS Lesions Over time

Time lapse = 1 year

Serum and CSF Analysis
 Blood tests
 Lumbar Puncture (spinal tap)
- If MS is present, persistent elevated
of CSF protein IgG (oligoclonal
antibody) bands can be seen in spinal
fluid which is an additional confirmatory
test.
Symptom Management –
Examples
 Pain control
 Management of impaired bladder and
bowel function
 Anti-spasmodic drugs
 Treatment of fatigue
 Splinting for contractures
 Counseling
The end..
References
 All About MS @  http://www.mult-sclerosis.org/
 Multiple Sclerosis Society @  http://www.mssociety.org.uk/
 The National Multiple Sclerosis Society @ http://www.nationalmssociety.org/
 All About MS @  http://www.mult-sclerosis.org/
 Multiple Sclerosis Society @  http://www.mssociety.org.uk/
 The National Multiple Sclerosis Society @ http://www.nationalmssociety.org
 Resource Link for the MS Foundation (MS Facts) @ http://www.msfacts.org/
 Barnes, David. Multiple Sclerosis Questions and Answers, Merit Publishing International, Florida, 2000
 O’Connor, Dr. Paul. Multiple Sclerosis The Facts You Need, Firefly Books Inc., New York, 1999.  
 Christopher Bourque, Diagnostic Issues
 Ref :“DEMYELINATING DISEASE MULTIPLE SCLEROSIS”ELLEN MARDER MD PHD, 8/4/2005
 Multiple Sclerosis: Hope Through Research, 06 April
2003http://intelihealth.com/IH/ihtIH/WSIHW000/8320/21151/195415.html?d=dmtcontent>,
 www.jama.com on February 14, 2009